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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700157
Report Date: 09/08/2021
Date Signed: 09/08/2021 06:39:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201116101918
FACILITY NAME:CHALET, THEFACILITY NUMBER:
342700157
ADMINISTRATOR:PATEL, NISHAFACILITY TYPE:
740
ADDRESS:6487 MAIN STREETTELEPHONE:
(925) 787-2740
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:41CENSUS: 12DATE:
09/08/2021
UNANNOUNCEDTIME BEGAN:
05:50 PM
MET WITH:Elsa Ruiz, caregiverTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff is not facilitating visitation between the resident and her family member.
Staff are not providing activities to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 09/08/2021 to deliver complaint findings for the allegations listed above, LPA met with caregiver Elsa Ruiz and explained the purpose of the visit. Prior to initiating visit LPA completed daily self-screening questionnaire to confirm no symptoms of COVID-19, LPA was screened by staff upon entry and wore a surgical mask and applied hand sanitzer. LPA contacted admin Nisha Patel over the phone to deliver findings, Nisha gave verbal persmission for Elsa to sign the report.

Throughout the course of the investigation the department reviewed documentation and conducted interviews relevant to the allegations: staff is not facilitating visitation between the resident and her family member and staff are not providing activities to resident.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20201116101918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CHALET, THE
FACILITY NUMBER: 342700157
VISIT DATE: 09/08/2021
NARRATIVE
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Documents reviewed revealed that there were activities planned during October, November and December 2020, however due to the pandemic and a COVID-19 outbreak the facility was on isolation orders from approximately November 16 – December 18, 2020, during this time residents were provided activities that could be done individually in their room. Interviews with staff revealed that facility did their best to accommodate virtual visits with their phones during this time.

Due to this information the department finds the allegations to be UNSUBSTANTIATED a finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and copy of report emailed to administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2